Common problems encountered when anaesthetic charts are examined by both lawyers and expert witnesses are exactly the same problems encountered with medical records in general.

Illegible handwriting has long been seen as a contributing factor in the root cause analysis of adverse incidents. If the chart is not easily readable then this increases the risk of subsequent problems. If the chart is illegible then, fundamentally, it cannot be used as a defence in a court of law. In addition, if medical records are not signed and/or dated then the validity of what is written may be called into question.

Other common problems include:

• Insufficient detail, e.g. not mentioning the grade of intubation, if difficulty was encountered
• Inaccuracies, e.g. poor charting of physiological data or incorrect drug dosages